Top doctors: Treating rheumatoid arthritis

Everyone gets a bit creaky with age, and most people develop some aches and pains from osteoarthritis, when the joint cushioning wears away.

Rheumatoid arthritis, however, is a different matter. This condition, which can occur quite early in life, develops when the immune system malfunctions.

Here's what you should know about treating rheumatoid arthritis:

1. The goal of medications is to subdue the immune system

Rheumatoid arthritis begins when the immune system attacks the lining of joints in the body, said Dr. Richard Furie, chief of rheumatology at the North Shore-Long Island Jewish Health System and a professor of medicine at Hofstra University.

"A joint normally has a very thin lining, almost like Saran Wrap, that's very thin and produces nutrients for the joint," he said. In rheumatoid arthritis, "the tissue starts to grow like crazy," he explained. "There's uncontrolled growth of this very thin membrane, and it begins to almost look like a sea anemone, with fronds that can invade and destroy cartilage, bone, ligaments and tendons."

Treatment may include anti-inflammatory drugs -- they reduce swelling -- and medications that directly modify the way the immune system works, Furie said.

2. Use nonprescription drugs with caution

Over-the-counter painkillers like ibuprofen and naproxen may help treat pain and swelling, but "they are not innocuous drugs," warned Dr. Steven E. Carsons, chief of the Division of Rheumatology, Allergy and Immunology at Winthrop University Hospital. "They may interact with other medications prescribed for rheumatoid arthritis, and carry a risk of gastrointestinal ulceration and bleeding as well as altering kidney function. Recent data urge caution in patients having risk factors for heart disease."

3. Drug combos have made a big difference

Over the past decade, combo therapies have helped improve symptoms for many people with rheumatoid arthritis, Carsons said. Sixty-five to 70 percent get at least some relief when they take a combination of medications, he said.

In particular, Carsons said, doctors have been prescribing combinations of methotrexate (an immune-system dampener known by the brand names Rheumatrex and Trexall) and drugs known as biologic agents. Furie explained that biologic drugs target a specific molecule in the immune system, and it may take time to find the right combination of medications for a patient.

"That's something we couldn't do 12 years ago because there weren't all these drugs out there," Furie said. "Now there are all these choices. It's great for the patients."

4. Treatment may be costly and not always totally covered by insurance

"The impact of cost is felt most acutely regarding the biologic therapies, which may reach $10,000 to $20,000 yearly," Carsons said. "Plans often do not cover the entire expense." But, he said, "rheumatologists and their staffs are knowledgeable in working with payers, manufacturers and private foundations in order to obtain these medications for their patients at a reasonable out-of-pocket expense whenever possible."

5. Side effects are possible but may be worth it

The immune-dampening medications can boost the risk of infections like respiratory diseases, and there's debate over whether they may make cancer more likely, Furie said. "You can't subdue the immune system without affecting the immune system's ability to protect you from invaders," he explained.

Still, he said, the drugs can have major benefits in the long run because they preserve the integrity and function of joints. Methotrexate, for example, slows down the damage from rheumatoid arthritis, he said.

"A lot of patients are afraid to go on medications because they're afraid of side effects, and they say they're doing OK now," Furie said. "I'll counter with, 'You're doing OK now, but we want to make sure you're doing OK 30 years from now.' There's a balance to be struck between feeling better now and the long-term outlook."

RHEUMATOLOGISTS

This is the 18th installment of a 26-week series in which Newsday presents Castle Connolly's list of top Long Island doctors.

Dr. Elise Belilos,

Winthrop Univ. Hosp.,

Div. Rheumatology,

120 Mineola Blvd.,

Mineola; 516-663-2097

Dr. Sheldon Blau,

566 Broadway,

Massapequa; 516-541-6262

Dr. Steven Carsons,

Div. Rheumatology & Allergy,

120 Mineola Blvd.,

Mineola; 516-663-2097

Dr. Daniel Cohen,

1157 Broadway,

Hewlett; 516-295-4481

Dr. Richard Furie,

North Shore Long Island

Jewish Health System,

2800 Marcus Ave.,

Lake Success; 516-708-2550

Dr. Robert Greenwald,

2 ProHealth Plaza,

Lake Success; 516-622-6090

Dr. Max Hamburger,

1895 Walt Whitman Rd.,

Melville; 631-249-9525

Dr. Michael Hoffman,

277 Northern Blvd.,

Great Neck; 516-498-3500

Dr. Alan Kaell,

315 Middle Country Rd.,

Smithtown; 631-360-7778

Dr. Esther Lipstein-Kresch,

2 Pro Health Plaza,

Lake Success; 516-622-6090

Dr. Gary Meredith,

242 Merrick Rd.,

Rockville Centre; 516-536-9424

Dr. Andrew Porges,

1044 Northern Blvd.,

Roslyn; 516-484-6880

Dr. Michael Repice,

5 E. Main St.,

Huntington; 631-271-1640

Dr. James Sullivan,

975 Stewart Ave.,

Garden City; 516-222-8654

Dr. Mark Tan,

222 Middle Country Rd.,

Smithtown; 631-724-8900

Dr. Louis Tiger,

566 Broadway,

Massapequa; 516-541-6262

How they were picked

Castle Connolly Medical Ltd. is a health care research and information company founded in 1991 by a former medical college board chairman and president to help guide consumers to America's top doctors and hospitals. Castle Connolly's established survey and research process, under the direction of a doctor, involves tens of thousands of doctors and the medical leadership of leading hospitals.

Castle Connolly's team of researchers follows a rigorous screening process to select doctors on national and regional levels. Using mail and telephone surveys, and electronic ballots, they ask physicians and the leadership of top hospitals to identify exceptional doctors. Careful screening of doctors' educational and professional experience is essential to the committee. Not every good physician makes the list. Rather, the list is a way for patients to get started on their search for the best medical professional. Newsday is not part of the selection process.

Doctors do not and cannot pay to be selected and profiled as Castle Connolly Top Doctors.

To see the whole list . . .

Who else is on the list of Top Doctors? More than 6,000 listings are in the New York Metro Area edition of "Top Doctors," published by Castle Connolly Medical Ltd. The softcover list price is $34.95. For more information, go to castleconnolly.com, or call 800-399-DOCS.